Contribute to the Long Covid Support Banner

Thank you for your interest in contributing to the Long Covid Support Banner.
This form is intended for individuals who are unable to send a fabric piece. By completing this form (or having a caregiver assist), we will create a fabric piece on your behalf to include in the banner.

Please note, there is no obligation to include any words on the fabric. If you prefer, we can simply add a piece of fabric on your behalf without any text.

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Name *
Email Address (optional)
If you’d like to stay updated on the banner, please provide your email address. 

Your details will remain confidential and will only be used for communication related to the banner project.
I would like a piece of fabric added to the banner on my behalf *
I would like my first name to be added to the piece of fabric *
Your Story or Message 
If you wish, please share a brief message, story, or thought that you would like to be represented on your fabric piece.  
Any Additional Details
Please provide any other requests you'd like included on the fabric. We will do our best to accommodate them.  

Consent
I understand that the fabric piece added on my behalf will be part of a banner that will be publicly exhibited and included in a film.  

*

How did you hear about the Long Covid Support Banner project?

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